Dysphagia

History

Fact

Explanation

Difficulty in swallowing (dysphagia)

This can be classified according to the area of origin, it can be oropharyngeal or oesophageal. In oropharyngeal dysphagia, patient complains accumulation of food in the mouth without entering it into the oesophagus. In oesophageal dysphagia, there is food stuck after passing through the mouth. It can get stuck behind the neck, middle of the chest or even lower down in the chest. Oesophageal carcinoma causes dysphagia when it is large enough to obstruct the oesophageal lumen. Therefore dysphagia in the oesophageal carcinoma is presentation of advanced disease. [5]

Progression of dysphagia

If the symptoms started as dysphagia for fluids and gradually progressing towards the solids, that might be an indicator of malignancy of the oesophagus. In conditions like achalasia cardia, and neuromuscular problems dysphagia is more towards the liquids. Duration of the dysphagia is also helpful to get an idea about the underlying pathology. Acute onset may be due to foreign body ingestion [7] stricture or carcinoma. Long term history will suggests conditions like achalasia cardia, [5] diffuse oesophageal spasms and nut cracker oesophagus like neuromuscular problems.

Odynophagia

This is painful swallowing which occurs due to the oral conditions like tonsilitis, candidiasis and thermal injuries etc, these can cause oropharyngeal dysphagia. [9]

Loss of weight, loss of appetite, hunger

May be a feature of malignancy of the oesophagus. Compared to the oesophageal carcinoma, where hunger is prominent, gastric carcinoma will have marked loss of appetite. [10]

Nasal regurgitation of the ingested materials, choking and coughing

Ingestion of food is followed by these symptoms in oropharyngeal dysphagia. [6]

Stroke can be a risk factor for the development of dysphagia. Most of the patients regain functional swallowing within the first month following stroke, but some will remain the dysphagia beyond that period. [1] Incidence of dysphagia ismore wiyth the brainstem lesionsthan hemispheric lesions.

Easy fatiguebility

Myasthenia gravis [6] is a disease where the problem is in the neuromscular junction.

Heart burn and regurgitation

These are symptoms of gastrooesophageal reflux disaese (GORD). GORD can produce strictures in the oesophagus. GORD and Barrett’s esophagus (migration of squamo- columnar junction) are risk factors for esophageal adenocarcinoma. [4]

Chest pain

Can be a feature of achalasia or GORD. Achalasis is a neuromuscular disorder of the oesophagusdue to the destruction of oesophageal myenteric plexus leading to aperistalsis and failure of the lower oesophageal sphincter relaxation with swallowing. [8]

History of corrosive, vinegar ingestion or exposure to radiation

Can cause strictures. [11]

History of foreign body ingestion

These can lodge in the oesophagus causing dysphagia. Most common ones are food boluses, batteries etc. [12]

Fever and productive cough

As the ingested materials are unable to go through the obstruction, there is accumulation above the obstruction. These patients are vulnerable for the recurrent aspiration and entrance of swallowed materials into the airway results in aspiration pneumonia. [1]

History of traumatic brain injury [2]

This is a neurological cause for dysphagia. Mostly due to the prolonged disturbance of consciousness. Impairment of the swallowing is mainly affects the voluntary component of swallowing such as oral dysphagia. [2]

History of parkinson’s disease

Repeated tongue pumping movements, delayed triggering of the pharyngeal phase, delayed onset of laryngeal elevation, are some of the suggested factors contributing to the dysphagia. [2]

Betal chewing, smoking

These are risk factors for the development of squamous cell carcinoma of the oesophagus which mainly affecs the upper two thirds of the oesophagus. [5]

Examination

Fact

Explanation

Pallor

May be due to malnutrition, malignancy of the oesophagus or Plummer winson syndrome/ Paterson-Brown-Kelly syndrome [7] where there is a combination of upper esophageal webs, postcricoid dysphagia, and iron deficiency anemia. Long-term, iron deficiency anemia is the cause for the disease.

Icterus

Disseminated malignancy into the liver can produce jaundice. [8]

Wasting

Due to malnutrition [1] and loss of weight in malignancy.

Koilonoychia, glossitis

There are associated nutritional deficiencies [1] due to the poor intake result in iron, vitamin B 12 deficiency. Plummer-Vinson syndrome is also associated with iron deficiency.

Fatiguebility

Seen in myasthenia gravis, ocular muscles can be used to demonstrate the fatiguebility. [3]

Focal neurological signs, facial nerve palsy

Stroke is a risk factor for the dysphagia. [1] They will have limb weakness, abnormalities in the muscle tone, power, abnormal gait(hemiplegic gait) and cranial nerve palsies.

Differential Diagnoses

Fact

Explanation

Oesophageal carcinoma

Oesophageal cancer is the sixth most common cause of cancer-related deaths in the world. [4] There are 2 types of oesophageal carcinoma. Squamous cell carcinoma affects the upper two thirds of the oesophagus. Adenocarcinoma of the oesophagus affects the lower third of the oesophagus. Predisposing factors for the adenocarcinoma will be gastrooesophageal reflux disease and Barrett's oesophagus. [5] Barrett's oesophagus is where squamous cell lining is replaced by columnar cells with extension of the squamo-columnar junction proximally. Betel chewing and smoking predispose to is squamous cell carcinoma. New onset progressive dysphagia in elderly person may be due to oesophageal malignancy. Incidence of adenocarcinoma is rising over the last two decades in developed countries. [1]

Achalasia cardia

Symptoms may be progressive dysphagia with long term history, odynophagia, and chest pain. Barium swallow gives the bird's beak appearance. Achalasia is a neuromuscular disorder of the oesophagus due to the destruction of oesophageal myenteric plexus leading to aperistalsis and failure of the lower oesophageal sphincter relaxation with swallowing. [2]

Gastrooesophageal reflux disease

Gastroesophageal reflux disease (GORD) is due to the mucosal damage caused by the abnormal reflux of gastric contents into the esophagus. Heartburn, regurgitation are the common symptoms. [3]

Stricture

Can be due to malignancy or benign conditions. Ingestion of vinegar, corrosives, gastroesophageal reflux disease (GORD) are some of the causes causing strictures. Reflux causes oesophagitis [3] that heals with scaring leaving a stricture.

Investigations - for Diagnosis

Fact

Explanation

Upper gastrointestinal endoscopy

Upper gastrointestinal endoscopy is the key investigation for the diagnosis of dysphagia. It can visualize the growths like malignancy in the walls of the oesophagus, ulcers and strictures. Ulcer, typical of friable hyperemic mucosa with necrotic debris with a tendency for easy to touch bleeding can be found in injuries to the mucosa due to hot beverages. [5] Endoscopy has diagnostic advantages such as biopsy and therapeutic advantages such as insertion of synthetic tubes and dilatation. [3]

Barium swallow

This will show a core of an apple appearance in malignancy of the oesophagus due to the malignant growth, bird's beak appearance is seen in achalasia cardia, corkscrew appearance in diffuse oesophageal spasm and stasis of barium in the pyriform sinuses is in globus pharyngeus. [2] This can not do the biopsy.

Oesophageal manometry

Used for the diagnosis of gastro oesophageal reflux disease. [6]

Edrophonium test [4]

Acetylcholine esterase inhibitor is given and the amount of acetylcholine is increased at the neuromuscular junction, that produces short term improvement of the fatigability. [4]

Serum iron and ferritin studies

Plummer Vinson syndrome is due to the long term iron deficiency anemia, that need evaluation of iron levels in the body. [1]

Investigations - Fitness for Management

Anaemia with low haemoglobin is found in malignancy, achalasia like chronic diseases and Plummer Vinson syndrome due to iron deficiency. [2]

Lung function tests, chest x-ray and echocardiogram

Oesophagectomy is a major surgery involving the thorax. On the other hand most of the elderly patients are having severe cardio respiratory co morbidities. [1] So pulmonary functions need to be assessed before the surgery.

Management - General Measures

Changes in body and head posture may be recommended reduce aspiration as this may the affects the speed and flow direction of a food or liquid bolus. [2,4]

Swallow maneuvers

These are are changes in the the normal swallowing to produce safe or efficient swallowing. Eg:- supraglottic and super supraglottic swallow techniques- voluntary breath holding, related to laryngeal closure to protect the airway during swallowing.
Mendelsohn maneuver to extend opening or relaxation of the upper esophageal sphincter. [2]

Diet modifications

If the person is unable to swallow the solids, it has to be replaced with liquids. Thickened liquids are a important compensatory intervention in long term caring to supply adequate nutrition. [2]

Management - Specific Treatments

Fact

Explanation

Surgery

Radical esophagectomy with radical lymph node dissection is the gold standard surgery for oesophageal squamous cell carcinoma. [7] Patients with advanced, inoperable tumor stages and severe comorbidities may not be suitable for surgery. Stage 0 or I disease is usually treated with surgery alone. Stage II and III disease is treated with surgery, with or without neoadjuvant therapy. Techniques of resection will be Ivor-Lewis, a thoracoabdominal approach, transhiatal that involves the abdomen and neck without thoracotomy the transabdominal, that is mainly for the lower gastroesophageal junction and thoracoscopic/laparoscopic, which is a minimally invasive approach. [8]

Ivor-Lewis oesophagectomy

Ivor-Lewis, involves a thoracoabdominal approach, where abdominal incision is made to mobilize stomach with preserving the gastroepiploic vessels and then thoracotomy to approach the oesophagus. This provides a better access to the oesophagus, lymph node dissection is possible, but there is a risk of mediastinitis as the thoracotomy is involved.
This approach is advantageous in decreasing the recurrent
nerve lesion and other complications associated with a cervical dissection. [10]

Mc Keown oesophagectomy [12]

This is an extension of Ivor Lewis method, where there are abdominal incision, thoracotomy and third neck incision. This is three stage approach with a cervical anastomosis that reduces the risk of mediastinitis. But this also has the thoracotomy associated morbidity. [12]

Transhiatal/Oringers oesophagectomy

Transhiatal/Oringers that involves the abdomen and neck without thoracotomy. Oesophagus is then connected to the stomach via cervical esophagogastric anastomosis. As there is no thoracotomy involved, this is a blind dissection and is suitable for middle and lower oesophageal malignancies. Complications will be thoracic or pulmonary complications such as pneumothorax, pleural effusions, pneumonias, empyemas, and respiratory failure and anastomotic leak. [9]

Video assisted thoracoscopic surgery

Laparoscopic and thoracoscopic techniques has been used as the the treatment of esophageal disorders such as oesophageal malignancy, achalasia and gastroesophageal reflux disease (GERD). Shorter hospital stay, less postoperative complications [13] , and early recovery are the advantages of this laparoscopic and thoracoscopic techniques.

Endoscopic dialatation

Can be used for the peptic strictures [1]

Insertion of stent

Stents are inserted in non operable patients with malignancy . [1] This can relieve dysphagia in 90% of patients. Stent can give rise to complications such as stent migration, blocking of the tube, perforation and infection. Self expanding metal stents are beneficial as it is associated with less complications and easy insertion. [3]

Neoadjuvant or definitive chemoradiotherapy

Chemotherapy, radiotherapy , and chemoradiotherapy can be combined with the surgery for the better outcome. [7] Preoperative neoadjuvant radiotherapy is used to down stage the tumour. Chemotherapy is with bleomycin, vindesine, 5-flurouracil or combination of these. These are used specially for the treatment of squamous cell carcinoma. This has shown to improve the survival compared with surgery alone.

Laser ablation therapy

Good as a palliative method. [11] This procedure is expensive, [3] Repeated treatments are needed for the success, it also as serious adverse effects.

Brachytherapy, photodynamic therapy or immunotherapy

Used to downstage the tumor in some patients. [8]

Management of gastroesophageal reflux disease

The main agents available for patients with GORD are antacids, H2-receptor antagonists, and proton pump inhibitors such as pantoprazole, omeprazole etc. [2] Chronic relapsing GORD requires long-term maintenance treatment.

Surgical resection of pharngeal pouch

Surgical resection of pharyngeal pouch will relieve the symptoms. [4]

Management of food bolus/foreign body

Ingested foreign body if stays at one place for a longer time needs extraction or moving it into the stomach via endoscopy. [5]

Management of achalasia cardia

Medical therapies for the achalasia are calcium antagonists or sildenafil with the aim of relaxing the smooth muscle of the lower oesophageal sphincter (LOS). Pneumatic dilatation using endoscope and injection of botulinum toxin provide short term improvement. Surgical management is cardiomyotomy that is to divide the muscle of the LOS longitudinally via transabdominal, transthoracic or thoracoscopic routes.[6]